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By Z. Frillock. Baker University. 2018.

Given the psychometric limitations of tests of malingering and the inher- ent difficulty with finding appropriate criterion groups for research in this area 50mg endep overnight delivery, it is best to rely on behavioral decision rules generic endep 25mg with amex. Williams (1998) sug- gested that psychologists should use three major areas in which discrepan- cies occur to construct a malingering index for traumatic brain injury endep 25mg without prescription. The first is the relationship of injury severity to cognitive functioning order 25 mg endep otc. The severity of the injury is directly related to the severity of the expected impairment. The second area involved noting the interrelationship of the tests and subtests. Williams opined, “Inconsistencies are expressed as scores that are sufficiently disparate that they violate the known relationships between the tests” (p. The third area involved the relationship between pre- injury status and current test results and, by extension, current functioning. In a forensic report the psychologist may point out inconsistencies but leave the determination of veracity to the “trier of fact. Response biases may also occur unwittingly as when the response is influenced by poor memory. Highly contentious situations often surround assessment of pain-related impair- ment and disability such as worker compensation, social security disability, veterans’ disability compensation, civil litigation related to accidental inju- ries (e. The validity scales of instruments such as the MMPI and the Eysenck Personality Inventory (Eysenck & Eysenck, 1975) and the variable response scale for the MPI (Bruehl, Lofland, Sherman, & Carlsom, 1998) are at times use in an effort to detect possible biases in patients’ responses. In a preliminary study, Lofland, Semenchuk, and Cassisi (1995) concluded the MPI “appears to be a good screening measure to detect patients who are exhibiting symptom exaggeration. There have been numerous attempts to identify specific psychological profiles of litigation and compensation patients. There is, however, no con- clusive evidence that specific characteristics differentiate those who are lit- igating or who are receiving disability compensation from those who are not (Kolbison, Epstein, & Burgess, 1996). The authors found no difference in the responses to any of the three sections of the in- strument—pain severity, emotional distress, and functional activities. The au- thors concluded that clinicians should not assume that patients who poten- tially have something to gain by poor performance (disability seeking) will inevitably exaggerate the burden of their pain and the resultant disability. Waddell and colleagues (Waddell, McCulloch, Kummel, & Venner, 1980) developed a system of behavioral signs designed to determine the validity of a psychological basis for a given patient’s pain report. Presumably, those patients showing a higher number of nonanatomic (nonorganic) signs with their pain report have a high degree of psychological factors contributing to their pain report. Other investigators have examined facial expressions of pain: the ability of observers to distinguish exaggerated pain expressions from healthy subjects and pain sufferers’ “real” expressions of pain (Craig, Hyde, & Patrick, 1991; Poole & Craig, 1992). Physical tests to evaluate suboptimal performance have also been used to detect malingering (Robinson, O’Connor, Riley, Kvaal, & Shirley, 1994). ASSESSMENT OF CHRONIC PAIN SUFFERERS 237 Some efforts are made to ask patients to repeat standard physical tasks and use discrepancy of performance (“index of congruence”) as an indication of motivated performance. Reviewing efforts to detect deception led Craig, Hill, and McMurtry (1999) to the following conclusion: “Definitive, empiri- cally validated procedures for distinguishing genuine and deceptive report are not available and current approaches to the detection of deception re- main to some degree intuitive” (p. There is a growing body of information concerning the ability of neuro- psychological tests to detect malingering (Inman & Berry, 2002). Additional research is needed, however, before strong conclusions should follow from performance on these measures. At best performance on neuropsycho- logical test should be combined with other confirmatory information. LINKING ASSESSMENT WITH TREATMENT During any assessment, it is helpful to think about how the data gathered will be used in treatment and, ultimately, how a patient’s assessment might be related to his or her outcome. Being mindful of treatment implications can assist the pain psychologist in asking better questions during the as- sessment. Additionally, psychologists need to ensure that their evaluations have addressed the referral question(s), that their reports are informative, and that they have made reasonable, appropriate, and helpful recommen- dations. Patient Differences and Treatment Matching There is a common assumption among many health care providers that pa- tients who have the same medical diagnosis require identical treatment.

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Body weight The majority of research has indicated that athletes changes are the best method of determining fluid are consuming adequate amounts of these micronutri- replacement amounts after exercise discount endep 10mg online. Five hundred ents; however endep 10mg generic, more research is necessary to ade- milliliters of fluid should be consumed for every 1 lb quately evaluate the B12 and folate status of athletes of weight lost (Shirreffs et al discount 50 mg endep mastercard, 1996) cheap 10mg endep with amex. VITAMINS MINERALS Most sedentary adults in the United States meet the Dietary Reference Intakes (DRIs) for the B vitamins Active individuals are encouraged to consume cal- involved in energy metabolism (vitamin B12, folate, cium in amounts consistent with the DRI for their age CHAPTER 14 NUTRITION 87 TABLE 14-3 Dietary Reference Intakes for Selected Minerals NUTRIENT LIFE STAGE GROUP RDA†/AI‡ UL§ SELECTED FOOD SOURCES Calcium Males Milk, cheese, yogurt, calcium-fortified foods 19–50 y 1000* mg/d 2500 mg/d Females 19–50 y 1000* mg/d 2500 mg/d Iron Males Meat and poultry (heme iron); fruits, vegetables, 19–50 y 8 mg/d 45 mg/d fortified grain products (nonheme iron) Females 19–50 y 18 mg/d 45 mg/d Zinc Males Red meats, fortified cereals 19–50 y 11 mg/d 40 mg/d Females 19–50 y 8 mg/d 40 mg/d SOURCE: National Academy of Sciences (1997; 2001). Athletes who perspire heavily or engage in Zinc intake is less than optimal for approximately 25% physical activity in hot conditions may be prone to of females in the United States (CSFII, 1994–1996) increased losses of calcium in sweat. If an individual (Ma and Betts, 2000), and it has been estimated that consumes calcium supplements, no more than 500 mg about 50% of female distance runners also have less should be consumed at any one time to enhance than optimal intakes (Deuster et al, 1989); however, absorption (Bergeron et al, 1998) (see Table 14-3). Transient shifts in CARBOHYDRATE LOADING, potassium may indicate that athletes need more potas- GLYCOGEN RESYNTHESIS, MUSCLE sium in their diets than what is recommended MAINTENANCE—CHO/PRO RATIO (Millard-Stafford et al, 1995). The modified carbohydrate loading regimen still maintain fluid balance and prevent muscle cramping; used today involves consumption of a diet initially however, sodium needs can typically be met by consisting of 60% carbohydrate. The athlete also adding salt while eating or eating foods that are manipulates the amount of exercise they perform known to be high in sodium. Chloride needs of ath- on a daily basis in a downward fashion (from 90 letes may also be increased compared to sedentary min down to 20 min) until the day before the event. Foods containing sodium often also con- The day before the event, the individual rests and tain chloride (Convertino et al, 1996). Recent studies have observed improved perform- because of menstruation, sweat losses, low consumption ance when carbohydrate has been ingested before of iron-containing foods, and myoglobinuria from high intensity and intermittent exercise lasting less muscle stress during exercise. Iron deficiency, as a result than 60 min (Below et al, 1995; Davis et al, 1997; of decreased iron stores, negatively impacts exercise Jeukendrup et al, 1997). Adequate intake of iron daily will help to ingested immediately to ensure rapid muscle ensure optimal performance (Schena, 1995). Athletes should consume 88 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE ~1. Some research has indicated that consuming car- gastrointestinal distress (Murray et al, 1989). Adding protein to carbohydrate probably does not the activity (Convertino et al, 1996). Data does indicate rehydrate with ~150% of fluid lost to completely that the optimal amount of carbohydrate required to rehydrate (Burke, 1997). The addition of protein to carbohydrate may allow athletes to recover faster and perform ERGOGENIC AIDS better during multiple training or competition bouts and may help to repair damaged muscle fibers. Although many prod- ucts are advertised as nutritional ergogenic aids, few FLUID REPLACEMENT BEVERAGES products are actually supported by research. Many purported ergogenic aids provide no benefit (but are During and after exercise of ~1-h duration, a fluid harmless, e. A common side effect itates increased consumption compared to water of this product is weight gain. Possible side effects include upset Some research suggests that even for intermittent, stomach, nervousness, irritability, and diarrhea. Tea, coffee, and sodas with fluid replacement beverages because the carbohydrate caffeine can provide 50–100 mg/serving. Most content will not increase the drive to drink or maintain advertisements use personal testimonials that may be fluid balance. In addition, carbonation will increase convincing, but are not based on research that has the carbon dioxide content in the stomach and can been duplicated and widely accepted. Caffeinated products can care professionals oppose the use of all nutritional CHAPTER 14 NUTRITION 89 ergogenic aids. Those who do recommend their use and creatine intake may help increase performance should examine the safety, efficacy, potency, and and power output for both long-distance runners and legality of the product before discussing the product sprinters, respectively. DIETARY SUPPLEMENTS/ENERGY BARS REFERENCES Dietary supplements can be found as pills, powders, Alaimo K, McDowell MA, Briefel RR, et al: Dietary intake of beverages, and bars.

The enteric nervous system innervates the viscera via a complex network of interconnected plexuses generic 10 mg endep amex. The sympathetic and parasympathetic systems are largely mutual physi- ological antagonists—if one system inhibits a function generic 50 mg endep, the other typically augments it purchase 50mg endep amex. There are buy endep 50 mg line, however, important exceptions to this rule that demonstrate complementary or integratory relationships. The mechanism most heavily involved in the affective response to tissue trauma is the sym- pathetic nervous system. During emergency or injury to the body, the hypothalamus uses the sym- pathetic nervous system to increase cardiac output, respiration rate, and blood glucose. It also regulates body temperature, causes piloerection, al- ters muscle tone, provides compensatory responses to hemorrhage, and di- lates pupils. These responses are part of a coordinated, well-orchestrated response pattern called the defense response (Cannon, 1929; Sokolov, 1963, 1990). It resembles the better known orienting response in some respects, but it can only occur following a strong stimulus that is noxious or frankly painful. It sets the stage for escape or confrontation, thus serving to protect the organism from danger. In a conscious cat, both electrical stimulation of the hypothalamus and infusion of norepinephrine into the hypothalamus elicit a rage reaction with hissing, snarling, and attack posture with claw ex- posure, and a pattern of sympathetic nervous system arousal accompanies this (Barrett, Shaikh, Edinger, & Siegel, 1987; Hess, 1936; Hilton, 1966). PAIN PERCEPTION AND EXPERIENCE 67 lating epinephrine produced by the adrenal medulla during activation of the hypothalamo-pituitary-adrenocortical axis accentuates the defense re- sponse, fear responses, and aversive emotional arousal in general. Because the defense response and related changes are involuntary in na- ture, we generally perceive them as something that the environment does to us. We generally describe such physiological changes, not as the bodily responses that they are, but rather as feelings. We might describe a threat- ening and physiologically arousing event by saying that “It scared me” or that “It made me really mad. Emotions are who we are in a given circumstance rather than choices we make, and we commonly interpret events and circumstances in terms of the emotions that they elicit. ANS arousal, therefore, plays a major role in the complex psychological experience of injury and is a part of that experience. Early views of the ANS followed the lead of Cannon (1929) and held that emergency responses and all forms of intense aversive arousal are undiffer- entiated, diffuse patterns of sympathetic activation. Although this is broadly true, research has shown that definable patterns characterize emotional arousal, and that these are related to the emotion involved, the motor activ- ity required, and perhaps the context (LeDoux, 1986, 1996). An investigator attempting to understand how humans experience emotions must remember that the brain not only recognizes patterns of arousal; it also creates them. One of the primary mechanisms in the creation of emotion is feedback- dependent sympathetic efferent activation. The afferent mechanisms signal changes in the viscera and other organs, whereas efferent activity conveys commands to those organs. Consequently, the ANS can maintain feedback loops related to viscera, mus- cle, blood flow, and other responses. In addition, feedback can occur via the endocrine system, which under the control of the ANS releases neurohormones into the sys- temic circulation. Because feedback involves both autonomic afferents and endocrine responses, and because some feedback occurs at the level of un- conscious homeostatic balance and other feedback involves awareness, the issue of how visceral change contributes to the creation of an emotional state is complex. The mechanisms are almost certainly pattern dependent, dynamical, and at least partly specific to the emotion involved. The feedback concept is central to emotion research: Awareness of physiological changes elicited by a stimulus is a primary mechanism of emotion. The psychiatric patient presenting with panic attack, phobia, or anxiety is reporting a subjective state based on patterns of physiological 68 CHAPMAN signals and not an existential crisis that exists somewhere in the domain of the mind, somehow apart from the body. Similarly, the medical patient ex- pressing emotional distress during a painful procedure, or during uncon- trolled postoperative pain, is experiencing the sensory features of that pain against the background of a cacophony of sympathetic arousal signals.

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Tenderness over the Achilles tendon implicates Achilles tendonitis as the source of pain 10 mg endep overnight delivery. A bursa lies between the anterior surface of the Achilles tendon and the calcaneus discount endep 75mg without prescription. Another bursa lies between the insertion of the Achilles tendon and the overlying skin generic 25 mg endep otc. If the patient has complained of trauma to the Achilles tendon or a sudden exertion in which pushing off from the patient’s toes resulted in severe pain buy 25 mg endep visa, swelling, and weakness in the calf, then the patient may have ruptured the Achilles tendon. If a defect in the Achilles tendon is present, you may be able to palpate it. Another good test for a rupture of the Achilles tendon is to have the patient lie in the prone position with the patient’s legs dangling off the edge of the examining table. If the foot fails to plantarflex or only partly plantarflexes, the patient probably has a ruptured Achilles tendon. Test the muscles of the ankle by first having the patient dorsiflex the foot against resistance (Photo 4). This tests the tibialis anterior muscle, which is innervated by the deep peroneal nerve (L4). Next, have the patient plantarflex the foot against resistance (Photo 5). This tests the patient’s gastrocneumius and soleus muscles, which are innervated by the tibial nerve (primarily S1). The anterior talofibular ligament (ATFL) attaches from the anterior por- tion of the lateral malleolus to the lateral aspect of the talar neck in the Ankle Pain 115 Photo 4. The ATFL is the most commonly sprained ankle ligament in part because it is the first to be stressed during inversion and plantar flex- ion. To perform this test, with the patient’s foot in a few degrees of plantar flexion, take hold of the patient’s lower tibia with one hand and grip the patient’s calcaneus with the palm of the other hand. Pull the patient’s calcaneus (and talus) anteriorly toward you while you simultaneously push the patient’s tibia posteriorly away from you (Photo 6). The ATFL is the only ligament resisting this ante- rior talar subluxation. Increased subluxation and/or a clunking sensa- tion with subluxation reflect a torn ATFL. The calcaneofibular ligament (CFL) attaches the fibula to the lateral wall of the calcaneus. To test for the integrity of the CFL and ATFL, invert the patient’s calcaneus and assess for gapping of the talar joint (Photo 7). Increased gapping (compared with the unaffected limb) indicates a torn ATFL and CFL and reflects ankle instability. The posterior talofibular ligament (PTFL) is the third ligament in the lateral ankle to be sprained. The PTFL attaches from the posterior edge of the lateral malleolus to the posterior aspect of the talus. Because of its position and strength, the PTFL is rarely torn except in severe ankle injuries, such as dislocation. Having assessed the integrity of the lateral ligaments, next assess the integrity of the MCL. Stabilize the patient’s leg by holding the patient’s tibia and calcaneus and evert the foot (Photo 8). Increased gapping at the medial ankle reflects a tear in the medial collateral ligament. Finally, if you are concerned about a possible stress fracture in the lower leg or foot, place a tuning fork onto the painful area or area of local- ized tenderness over the bone. Plan Having completed your history and physical examination, you have a good idea of what is wrong with your patient’s ankle. Here is what to do next: Suspected ankle sprain Additional diagnostic evaluation: The Ottawa ankle rules were designed to offer an evidence-based approach to determine which patients with a suspected ankle sprain require X-rays and which do not.

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Consequently buy 50mg endep otc, ex- cessive loading should be avoided particularly dur- ing early puberty buy 50mg endep overnight delivery. Beunen GP order 25 mg endep mastercard, Malina RM buy endep 10mg overnight delivery, Renson R (1992) Physical activity and growth, maturation and performance: A longitudinal study. Dorizas J, Stanitski C (2003) Anterior cruciate ligament injury in the skeletally immature. Herman M, Pizzutillo P, Cavalier R (2003) Spondylolysis and spon- dylolisthesis in the child and adolescent athlete. Hasler C, Dick W (2002) Spondylolyse und Spondylolisthesis im Wachstumsalter. Hatton J, Pooran M, Li C, Luzzio C, Hughes-Fulford M (2003) A short pulse of mechanical force induces gene expression and growth in MC3T3-E1 osteoblasts via an ERK 1/2 pathway. Hefti F, Morscher E (1985) Die Belastbarkeit des wachsenden Be- wegungsapparates. Hefti FL, Kress A, Fasel J, Morscher EW (1991) Healing of the tran- sected anterior cruciate ligament in the rabbit. Mankin K, Zaleske D (1998) Response of physeal cartilage to low- level compression and tension in organ culture. Morscher E (1968) Strength and morphology of growth cartilage under hormonal influence of puberty Reconstr. Karger, Basel New York (Surgery and Traumatology, vol 10) 3 Diseases and injuries by site 3. History To ensure that the patient’s back is at eye-level, the examiner himself should not stand but preferably ▬ Trauma history: Has trauma occurred? Inspection from behind – What was the patient doing (sport, playing, normal We observe the position of the shoulders, the height routine)? We look for pigmentation over the ▬ Pain history: spinous processes, especially over the lumbar spine, Where is the pain located (neck, upper thoracic spine, as this can be an indication of (usually pathological) lower thoracic spine, lumbar spine, lumbosacral kyphosis in this area. If so, does the pain occur We assess the sagittal curves and establish a pos- only while changing position, or does the pain cause tural type: normal (physiological) back, hollow back the patient to wake up at night? Does the pain occur (increased thoracic kyphosis and lumbar lordosis), on bending down or straightening up again? Does the fully rounded back (kyphosis extending down to the pain also radiate to the legs? Does the pain occur on lumbar area), hollow-flat back (hyperlordosis of the coughing or sneezing? If Scheuermann disease is suspected backwards or forwards, then postural variants are ask specifically whether the patient is involved in cycle involved rather than (fixed) pathological changes. Are We observe whether a ventral or dorsal overhang is pres- there problems of micturition or defecation? Small children may need to stand on a box so that the iliac crest is at the examiner’s eye level. Girls who have reached puberty should also a be allowed to wear their brassiere. In order to assess posture-related muscle performance, 3 Matthiass has proposed the arm-raising test. The child is asked to stand as straight as possible and raise his arms and keep them in a horizontal position. A child or adoles- cent with normal postural capacity is able to maintain this position, in contrast with a child with postural weakness (⊡ Fig. We now ask the child to bend down as far as pos- sible while keeping the knees perfectly straight. Nor- a b mally, children and adolescents should be able to touch the floor with their fingertips or even place the whole palm of their hand on the floor. Ventral and b dorsal overhang: A vertical line from the cen- measure the distance from the fingertips to the floor in ter of the shoulders falls in front of or behind the center of the ankle a b c d e ⊡ Fig. Pelvic tilt: The forward and downward pelvic tilt in relation back, d hollow-flat back, e flat back to the horizontal is normally approx. Arm-raising test according to Matthiass:The child is asked to maintain this position (a), in the case of a postural weakness this to stand as straight as possible and raise his arms and keep them in a posture is lost (b), while a child with extremely weak muscles cannot horizontal position.

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